Research Article

ISSN: 2574 -1241 DOI:

10.26717/BJSTR.2019.15.002667 Assessment of Dentists’ Knowledge Concerning the Management of Pregnant Women in the Dental Office

Ilea A1, Lazăr AC1, Morar AE2, Boșca AB*3, Băbțan AM1, Petrescu NB1, Uriciuc WA1, Feurdean CN1, Câmpian RS1 and Șovrea A3 1Department of Oral Rehabilitation, Oral Health and Dental Office Management, Faculty of Dentistry, “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania 2Postgraduate student of Faculty of Dentistry, “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania 3Department of Histology, Faculty of Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania *Corresponding author:

Lecturer Bianca Adina Boșca, Department of Histology, Faculty of Medicine, “Iuliu Haţieganu” University of Medicine Cluj-Napoca, Str. L. Pasteur, No. 4, Cluj-Napoca, Romania

ARTICLE INFO abstract

Received: Introduction: Published: February 11, 2019 Pregnancy is a physiological condition characterized by multiple chang- February 26, 2019 es in the entire woman’s body, including the oral cavity. Gingival hyperplasia, gingivitis, py- Citation: ogenicPurpose: granulomas and some salivary changes are common conditions in pregnant women.

Ilea A, Lazăr AC, Morar AE, To assess the dental practitioner’s medical knowledge regarding the dental maneuvers allowed during pregnancy and the drug prescriptions for these patients in the Boșca AB, Băbțan AM, et al. Assess- Methodology: ment of Dentists’ Knowledge Con- dental office. cerning the Management of Pregnant In the present study, 128 active dentists with professional experience Women in the Dental Office. Biomed of one to 30 years were included. An online questionnaire was applied using the www. J Sci & Tech Res 15(2)-2019. BJSTR. isondaje.ro platform. The questionnaire was intended to be anonymous, with responses Keywords: MS.ID.002667. being collected online. The first set of questions assessed the socio-demographic data, the Pregnancy; Dental Treat- specialization, and the professional experience. The second set of questions referred to the ment; Dentistry; Dental Procedures; therapeutic approach of the pregnant women: the type of treatment and the period during Medical Education pregnancy when they chose to perform the dental treatments. The third set of questions re- ferred to the dental X-rays recommendation in pregnant women. The last category of ques- tionsResults: addressed to the medication prescribed or administered to pregnant patients. The data were quantified by calculating the arithmetic averages. Most partic- ipants had experience in the medical dental practice, therefore the answers were relevant for this study. More than half of the doctors surveyed stated that they would only treat a pregnant woman in emergency situations. Less than half would treat a pulp pathology only in emergency, but a pulp gangrene at any time during pregnancy. Regarding the extractions, the majorityConclusion: of the dentists would prefer to delay the treatment. An important number of dentists have insufficient knowledge related to the dental treatments that can be performed in a pregnant woman. Therefore, post-gradu- ate courses are required in order to up-date the knowledge of dentists.

Introduction Systemic Physiological Adaptations in the Body During Pregnancy Pregnancy is a physiological condition characterized by multi- ple changes in the entire the woman’s body, including the oral cav- ity. Maintaining the dental and oral health during pregnancy is cru- The systemic changes that occur in pregnancy encompass var- cial, since there are specific limitations in the treatment of several ious anatomical and physiological adaptations in order to nurture oral diseases. Copyright@ 11188

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DOI: 10.26717/BJSTR.2019.15.002667 and to accommodate the developing fetus. These changes begin af- first trimester, especially during the first 13 weeks of gestation. ter the conception and affect every system in the body such as: According to the potential adverse effects and the risk to the fetus (1,6,7), US Food and Drug Administration (FDA) classified drugs a. Increased number of blood cells and plasma volume into five categories: b. Increased level of coagulation factors A. A - Human studies showed no risk to the fetus, c. Increased fibrynolitic activity B. B - Animal studies reported no fetal risk; there are d. Iron deficiency and anemia no studies in pregnant women; E.g: Amoxicillin, Cephalexin, e. Tachycardia Chlorhexidine, Clindamycin, Erythromycin, Metronidazole, Penicillin, Acetaminophen, Ibuprophen, Lidocaine, Prilocaine, f. Increased cardiac output Pilocarpine, Prednisolone,

g. Increased heart rate C. C - Animal studies reported a risk to the fetus; no studies h. Movement of the diafragm to the top have been performed on pregnant women; E.g: Ciprofloxacin, Clarithromycin, Codeine with acetaminophen, Hydrocodone with i. Increased risk of apneea and dyspneea acetaminophen, Bupivacaine, Epinephrine, Mepivacaine;

j. Hyperventilation D. D - These drugs should only be used in exceptional cases; k. Nausea and vomiting E.g: Gentamicin, Doxycycline, Tetracycline;

l. Stomach acid burns E. X - Risks of using these drugs in pregnant women are muchAnalgesics: higher than benefits [5-7]. m. Behavioral changes The most common analgesic used during pregnancy n. Increased nutritional needs [1]. Decompensation of Different Organs is acetaminophen (Paracetamol). This is the safest, being included in category B by the FDA. The most commonly reported side effect of paracetamol is hepatotoxicity [1,8]. Other analgesics, such as During pregnancy, the normal function of various organs can ibuprophen, are also included in category B, but only in the first be impaired, resulting in pathological manifestations that could and second trimesters. In the third trimester, it falls into category interfereGestational with the oral Diabetes therapeutic Mellitus interventions. (GDM): D because it decreases the amount of amniotic fluid, and also limits Is defined as the vaginalAntibiotics: dilation during labor [1,9]. hyperglycemia that occurs for the first time during pregnancy. This Most of the antibiotics recommended by the may include cases of type 2 diabetes that have not been previously dentists are classified in category B, except for gentamicin, diagnosed but became symptomatic in early pregnancy, and true doxycyclineGentamicin and tetracycline, has been Reportedwhich are included to Cause in Fetalcategory Toxicity: GDM which occurs later. GDM affects between 2 and 5% of pregnant women. Untreated, GDM could induce, besides the general complications, oral diseases, such as gingivitis and periodontal Whereas doxycycline and tetracycline cause dental dyschromia and diseaseArterial [2]. Hypertension: have a detrimental effect on bone development. Ciprofloxacin, a Actinobacillus broad-spectrum antibiotic, is commonly prescribed in periodontal is one of the most common diseases associated with infection. Recent evidence medical disorders in pregnancy and could lead to maternal fetal suggest that Ciprofloxacin is involved in arthropathy and has severe complications. The dentist should collaborate with the cardiologist effects on cartilage developing, therefore it is not recommended or the gynecologist before performing any dental treatment if the for pregnant women [10]. Metronidazole, included in group B, is pregnant woman suffers from hypertension, especially severe banned in the first trimester because it has teratogenic effects [11]. hypertension,Conditions and Requiring is under anti-hypertensive Anticoagulant Therapy:medication [2,3]. Oral Manifestations During Pregnancy

If heparin is administered to the pregnant patient and a bleeding oral Oral manifestations during pregnancy include gingival intervention is necessary, the dentist should ask the physician hyperplasia, gingivitis, pyogenic granulomas and some salivary to adjust the dose of anticoagulant in order to ensure an INR changes. Oral health should be closely assessed and monitored both Drug(International Administration Normalised to Ratio) the Pregnant value lower Women than 2.2. [2,4]. before and during pregnancy. However, if the exacerbation of an oral disease occurs during pregnancy, the dentist should be aware that dental treatments are not completely contraindicated. The Since most medicines have side effects, these should be most appropriate time to perform dental treatments is the second avoided during pregnancy and administered only in serious trimester of pregnancy. The dental treatments in the first trimester conditions. Thus, the use of medication is not recommended in the of pregnancy is influenced by manifestations such as: accentuated Copyright@ 11189

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DOI: 10.26717/BJSTR.2019.15.002667 vomiting reflex, drowsiness and fatigue. In the third trimester, only be performed only using appropriate protection. In the 9th month emergencyGingivitis: and short interventions are recommended [2,5,12]. of gestation, the risk for fetus is much reduced [5]. The National Commission for Radiation Protection argues that fetal exposure Gingivitis is an acute and superficial inflammation at 50 mSv will not cause congenital defects, and if a radiological of the marginal gingiva and interdental papilla, that occurs mostly examination is essential for establishing the diagnosis, it is allowed in the second or third trimester of pregnancy. Local signs include: [16]. The opportune moment to perform an X-ray during pregnancy erythema, hyperplasia, increased amount of gingival sulcular fluid, Aimis the second trimester [17]. increased volume of the marginal gingiva and interdental papillae, with the formation of false periodontal pockets. The anterior part of the dental arches is the most affected, but gingivitis can The aim of our study was to assess dental practitioners’ be localized in a group of teeth or even generalized in the entire knowledge regarding the drug prescription and the particularities oral cavity [13,14]. The local examination usually reveals elevated Materialof the dental and therapeutic Methods procedures performed during pregnancy. bacterial plaque counts, gingival bleeding, and false periodontal pockets with epithelial insertion still maintained, and no alveolar boneThe resorption. Pregnancy After Epulis: birth, these changes usually disappear [4]. In this study, we assessed the knowledge of dental practitioners regarding the management of pregnant women in the dental office The pregnancy epulis is a tumor- by distributing an online questionnaire using the www.isondaje. like lesion situated on the gingiva, but may also develop on the ro platform. The study was attended by 128 dentists, of various tongue, lips, jugular mucosa, or palate [13]. It is less common than specialties, aged between 24 and 55 years, of which 123 practiced gestational gingivitis and occurs in the second or third month of in the urban area, and 5 in the rural area. The questionnaire was pregnancy. The epulis is the result of an increased inflammatory intended to be anonymous, with the responses collected online. response to the dental plaque and other irritants. Favorable The time for completing the questionnaire was unlimited, with an factors are: poor oral hygiene, presence of tartar and high levels of average duration between three and four minutes, depending on progesterone in the gingival tissues [15]. The lesion is soft upon the answers chosen, including mandatory and optional questions. palpation, grows rapidly and bleeds easily [4,13]. The pregnancy The first set of questions (1 to 3) referred to the socio-demographic epulis generally regresses in up to 3 months after birth. Surgical data including the medical specialty. The second set of questions (4 removal of the epulis is recommended if the lesion does not regress to 9) referred to the therapeutic approach of the pregnant women: afterAcute this interval Pulpitis: [4]. the medical procedures they perform and what period during Acute pulpitis should be prevented by pregnancy they chose for the dental treatments. These questions prophylaxis and regular check-ups. The correct treatment had five variants of choice, with the possibility of one or multiple consists in vital pulpectomy under plexal anesthesia without a choices. The answer options were: vasoconstrictor, administered by gentle maneuvers [5]. Devital a. Only in case of emergency, pulp extirpation is contraindicated because the diffusion of the devitalizing substances beyond the root apex which cannot be b. Only in the first trimester, controlled. However, if such a procedure is required, an arsenic-free c. Only in the second trimester of pregnancy, devitalizerPulp Necrosis: is recommended [5]. d. Only in the third trimester and Pulp necrosis is difficult to manage during pregnancy. Asymptomatic teeth with necrotic pulp affected e. At any time during pregnancy. before pregnancy should be extracted. Several cases of repetitive The tenth question referred to the dental radiographs spontaneous abortions have been reported in patients due to recommendation in pregnant women. This question had five dental infections [5]. Bleeding Dental Treatments and Imagistic Investigation variants of choice, with the possibility of several options: in Pregnant Women a. I do not want to be responsible for some complications, Dental Extraction: b. Only in the first trimester, Extractions can be performed after the c. Only in the second trimester, 4th month and before the end of the 8th month of pregnancy. The extraction is recommended to remove only the symptomatic teeth d. Only in the third trimester and thatDental cannot Radiographybe recovered butin Pregnant could generate Women: local are suppurations contraindicated [5]. e. Yes, at any time during pregnancy.

The last set of questions (11 and 12) addressed to the admin- throughout pregnancy by some authors. Radiographs are strictly istration of the anesthetic substance and the type of medication contraindicated in the first 8 months of pregnancy, and especially used or prescribed in pregnant patients. These questions had two during the first trimester. In exceptional cases, the radiographs can Copyright@ 11190

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DOI: 10.26717/BJSTR.2019.15.002667 variants of response: (a) no and (b) yes, and it was followed by an dental prosthetics (8.59%), 8 dento-alveolar surgeons (6.25%), 7 open question regarding the most frequently prescribed anesthet- specialists in endodontics (5.46%), 3 orthodontists (2.34%) and 2 ic or antibiotic, respectively. The statistical processing of the data specialists in periodontics (1.56%). Therefore, the best represented employed Microsoft Excel, and the results were presented by de- Thespecialty Therapeutic was general Approach dentistry. and the Medical Procedures Resultsscriptive statistics. Performed in Pregnant Women Dentists’ Distribution According to their Age

To the question regarding their attitude during the anamnesis Out of the 128 subjects, six dentists (5%) were under 25 years when they are informed that the patient is pregnant, none of the of age, 85 dentists (66%) were aged between 26 and 35 years, 32 dentists would refuse to treat her (the first option), 2 dentists dentists (25%) were aged between 36 and 45 years, and 5 dentists (1.6%) would send the patient to the specialized medical services were aged between 46 and 55 years (4%). The group consisting of in case of emergency (the second option), 86 doctors (67.2%) dentists aged between 26 and 35 years, was the largest, followed by chose to perform only procedures that do not require anesthesia the group of dentists aged between 36 and 45 years. These results (the third option), and 40 doctors (31.2%) would treat a pregnant can be explained by the experience of the young doctors in using woman like any other patient (the last option). Thus, the third approach was chosen by most of the dentists. One third of the Dentists’the online environment.Distribution According to the Medical Specialty attending physicians would treat the pregnant woman as if she was a regular patient, without considering any of the particular aspects The participants in the study included: 97 specialists in or risks regarding this condition (Figure 1). general dentistry (75.7%), 11 dental practitioners specialized in

Figure 1: Graphical representation of the dentists’ attitude regarding the therapeutic approach of a pregnant woman.

Dental Treatments in the Pregnant Patient

a. Only three answers (1.8%) were option

The fourth question referred to the period during pregnancy b. 41 answers (24.1%) were option three when a dental treatment can be performed had five variants of c. 8 answers (4.7%) were option and choice, with the possibility of one or multiple choices. The answer options were: d. 63 answers (37%) were the last option

a. Only in case of emergency, e. The majority of the answers were the two opposite options: would perform the dental treatment at any time or would b. Only in the first trimester, Endodontictreat pregnant Treatment patients only of in Pulpcase of Diseases emergency. in the Pregnant c. Only in the second trimester of pregnancy, Patient d. Only in the third trimester and

e. At any time during pregnancy. The fifth question referred to the period during pregnancy Since it was a question with several possible choices, there were when the endodontic treatment can be performed. Since it was a 170 answers, of which 55 answers (32.4%) were the first option question with several possible choices, there were 172 responses, among which: Copyright@ 11191

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a. 74 answers (43%) were the first option, d. 10 answers (5.8%) were the fourth variant and

b. Only 4 answers (2.3%) were the second option, e. 39 answers (22.7%) were the last option (Figure 2).

c. 45 answers (26.2%) were the third option,

Figure 2: Graphical representation of the appropriate period for the endodontic treatments performed in pregnant patients.

Endodontic Treatment of the Necrotic Pulp in the

Pregnant Patient b. Only 2 answers (1.2%) were the second option,

c. 29 answers (17.7%) were the third option, The sixth question referred to the period during pregnancy d. 7 answers (4.3%) were the fourth variant and when the endodontic treatment for pulp necrosis can be performed. There were 164 answers, of which: e. 71 answers (43.3%) were the last option.

a. 55 answers (33.5%) were the first option, The last option collected the majority of the answers, followed by the first variant (Figure 3).

Figure 3: Graphical representation of the appropriate period for the endodontic treatment of the pulp necrosis performed in pregnant patients.

Specific Treatment for Gingivitis in the Pregnant Patient

b. Only 4 answers (2.9%) were the second option,

The seventh question referred to the period during pregnancy c. 12 answers (8.7%) were the third option, when the treatment for gingivitis can be performed. d. 4 answers (2.9%) were the fourth variant and a. There were 138 answers, of which 21 answers (15.2%) e. 97 answers (70.3%) were the last option. were the first option, Copyright@ 11192

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The last option was chosen by the majority of the dentists, e. 7 answers (4.3%) were the last option. showing that most subjects were well informed about gingivitis- The first variant was chosen by most of the dentists, showing specific treatment. A low percentage of the respondents would that they would postpone the extraction, until after birth. About a treat gingivitis only in emergency. Specific Treatment for Chronic Periodontitis in a quarter of participating doctors would perform the extraction in Pregnant Patient the second trimester of pregnancy, and the fewest would extract Dentalteeth anytime x-rays during in a Pregnantpregnancy. Patient

The eighth question referred to the period during pregnancy when the treatment for chronic periodontitis can be performed. In response to the tenth question, there were 135 answers, of There were 152 answers, of which

a. Which 60 answers (39.5%) were the first option, a. 93 answers (68.9%) were the first option,

b. Only 3 answers (2%) were the second option, b. Only 1 answer (0.7%) was the second option,

c. 24 answers (15.8%) were the third option, c. 23 answers (17%) were the third option,

d. 4 answers (2.6%) were the fourth option and d. 11 answers (8.1%) were the fourth option and

e. 61 answers (40.1%) were the fifth option. e. 7 answers (5.3%) were the last option.

Therefore, the opposite options collected the most numerous Most of the dentists chose the first option, showing that they answers. This can be explained by the fact that the question was not do not want to be responsible for potential complications of X-rays clear enough about the type of treatment required. Dental Extraction in the Pregnant Patient Usein the of fetus. Anesthetic Substances in the Pregnant Patient

The ninth question referred to the period during pregnancy In response to this question, the total of 128 answers were dis- when the extractions can be performed. There were 159 responses, tributed as follows: 41 answers (32%) were negative, and 87 an- a. Of which 107 answers (67.3%) were the first option, swers (68%) were affirmative. The 87 responses referring to the most frequently used anesthetic substances were divided as fol- b. Only 2 answers (1.3%) were the second option, lows: articain (49.4%), mepivacaine (43.7%) and lidocaine (6.9%) c. 34 answers (21.4%) were the third option, (Figure 4).

d. 9 answers (5.7%) were the fourth option, and

Figure 4: Graphical representation of the most frequently used anesthetic substances in pregnant patients.

Prescription of Antibiotics in the Pregnant Patient

the 45 responses were distributed as follows: amoxicillin (40%), augmentin (31.1%), prescribed only after consulting the In response to this question, the 128 answers were divided gynecologist (15.4%), ampicillin (8.88%), zinnat (2.26%), any into 83 negative responses (64.8%) and 45 affirmative responses compatible antibiotic (2.26%) (Figure 5). (35.2%). Regarding the most frequently prescribed antibiotics,

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Figure 5: Graphical representation of the most frequently prescribed antibiotics in pregnant patients.

Discussion mechanical treatment and sterilization of the root canals, root canal filling and coronary reconstruction. The tooth extraction is Maintaining the dental and oral health is essential during indicated when the pulp necrosis is complicated with periapical pregnancy. Alteration of overall health and the medical periodontitis and the tooth is severely affected, and the coronary interventions during pregnancy may have negative effects on the reconstruction is impossible. If considered an emergency, 33.5% of development of the fetus. Even if they are aware of the importance the dentists would treat this pulp pathology. Most doctors, 43.3%, of maternal oral health, many dentists have a reserved attitude consider this pathology to be treated at any stage of pregnancy. when in the position to provide dental care to pregnant women due to the risks involved [18]. Moreover, the lack of consensus between Gingivitis is an inflammation of the gingiva, often caused by the dentists and gynecologists, could be a significant discouragement accumulation of bacterial plaque and tartar which cause irritation for pregnant women seeking dental care [19]. In our study, all and induce inflammation. First-treatment plan is professional the dentists of different specialties (dento-alveolar surgery, scaling and professional cleaning performed in the dental office. A periodontics, endodontics, prosthesis, orthodontics, and general percentage of 70% of the dentists would treat this gingival affliction dentistry), would agree to treat a pregnant patient regardless of the at any stage of pregnancy and 15% only emergency cases. Dental period of pregnancy. However, about one third of dentists would extraction is a challenge for the dentists, especially if the patient treat a pregnant woman like any other patient, thus ignoring the is pregnant. Extractions can be performed between the 4th month potential complications and risks. Dental problems challenged of pregnancy and the end of the 8th month of pregnancy (2nd most of the doctors participating in our study. More than one third trimester and partly 3rd trimester) [13]. Most practitioners (68%) of the doctors would perform a dental treatment anytime during consider that this procedure should only be done in emergency pregnancy, and about the same number of doctors were at the situations. A very small percentage (4%) would perform a dental opposite position and would treat only serious cases. extraction anytime during pregnancy. The most commonly used anesthetic substances, which, according to the responses given If the patient experiences pain located at the level of a tooth by the doctors, were: articaine (49%), mepivacaine (44%) and affected by profound dental caries, also involving pulp pathology and lidocaine (7%), could have some side effects in pregnant patients. an endodontic treatment is required, it should be done regardless Once absorbed in the general circulation, these substances can of the stage of pregnancy. The elective treatment consists of vital penetrate the placental barrier and reach the fetus. Although the pulpectomy under plexal anesthesia without vasoconstrictor toxic effect of these anesthetics is well known, a high percentage [5]. As an emergency, acute pulpitis should be treated by 43% of (68%) of the dentists would use these substances, whereas 32% the doctors in our study. Approximately a quarter of the doctors would not use them in dental procedures. Although lidocaine is consider the second trimester to be the most appropriate for preferred, the preference for articaine could be explained by its wide such treatments. For dental pulp necrosis, there are two possible use in current dental procedures. Of the total respondents, one- therapeutic approaches: conservative treatment or extraction. The third would not perform anesthesia in a pregnant woman without conservative treatment aims at preserving the tooth and involves considering the risk-benefit factors. According to the international several steps: removal of the necrotic and infected pulp tissue, Copyright@ 11194

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DOI: 10.26717/BJSTR.2019.15.002667 literature, some authors recommend that no dental x-rays [13] postgraduate courses would be necessary for updating the medical should be performed during the first 8 months of pregnancy. Acknowledgmenteducation of dental practitioners.

However, there are studies that have shown that exposure to radiation during dental x-rays is very low, being harmless to a Aranka Ilea, Adela Cristina Lazar and Adriana Emanuela Morar pregnant patient [17]. Physicians participating in this study do Referenceshave equals contributions as first authors of the article. not perform dental x-rays in a proportion of 68.9%. A study in 1. the Davangere district in Karnataka, India, assessed the dentists’ Naseem M, Khurshid Z, Khan HA, Niazi F, Zohaib S, Zafar MS (2016) Oral awareness regarding the treatment protocols in pregnant women. health challenges in pregnant women: Recommendations for dental care The conclusions were that there is a clear lack of knowledge about 2. professionals. The Saudi Journal for dental research (7):138-146. the proper management of pregnant women, and dentists require Kumar J, Renee S (2009) Oral health care during pregnancy recoman- continuous medical education and a postgraduate curriculum for dation for oral health professionals. New York State Dental Journal 18: 3. 29-33. the management of such situations [13]. Another study, conducted in Brazil, assessed the current knowledge and recommendations Singla N, Singla R (2013) Oral Health Care during pregnancy. Guident 4. 6: 64-66. of gynecologists and dentists regarding dental care in pregnant Dumitru A, Păunică S, Giurgiu M, Cureu M (2009) Măriri de volum gin- women. The questionnaires approached the following issues: the gival, clinică și principii de tratament (Eds.), Didactică și pedagogică, oral health during pregnancy, the collaboration between prenatal 5. București, Romania. care providers and dental services providers, the administration Grigore B (2002) Reabilitare Orală. Medicală Universitară Iuliu Hațiega- of prenatal fluoride supplements, the selection of local anesthetic 6. nu, Cluj-Napoca, (Eds). Romania. substances for pain control, the treatment of infections and the Krauer B, Krauer F (1977) Drug kinetics in pregnancy. Clin Pharma-coki- 7. dental procedures which can be performed during every quarter. net 2(3): 167-181. Most doctors only provided dental care when a dental problem was Andrade S, Gurwitz J, Davis R, Chan K, Finkelstein J, Fortman K (2004) Prescription drug use in pregnancy. Obstetrics Gynecology 191(2): 398- mentioned, with limited prophylaxis. 8. 407. rd The results showed that dental management during pregnancy Grahame Smith D, Aronson J (2002) Oxford textbook of clinical pharma- 9. still had some deviations from the recommendations in the cology and drug therapy. Oxford University Press; (3 edn.), 95(9): 472. literature, indicating the need for updating the knowledge of these (1994) Teratology Society Public Affair Committee. FDA classification of 10. drugs for teratogenic. Teratology pp. 446-447. two categories of health professionals [19,20]. In France, a study conducted on 460 health professionals, 100 gynecologists and Bomford J, Ledger J, O`Keeffe B, Reiter C (1993) Ciprofloxacin use during 11. pregnancy. Drugs 45: 461-462. midwives, and 360 dentists, evaluated the knowledge, the approach and the daily medical practices. Their knowledge regarding the oral Kazy Z, Puho E, Czeizel A (2005) Teratogenic potential of vaginal metro- nidazole treatment during pregnancy. Journal of Obstetrics and Gynecol- changes during pregnancy, the possible association of periodontal 12. ogy 123(2): 174-178. pathology with premature birth and low birth weight and behavior Cristian M, Chiriac I, Cristian G, Vlădăreanu R, Gheorghe M (2010) Par- towards their patients were assessed. The most common oral ticularități ale tratamentului stomatologic în sarcină. Revista Română de 13. manifestations mentioned by all the practitioners were gingival Stomatologie 4(56):269-271. bleeding and gingivitis. All professionals have shown a lack of Roman A (2001) Parodontita asociată factorilor sistemici, implicații ter- 14. apeutice, Teodesco, Cluj-Napoca, (Eds.). Romania. information on the subject. The results highlighted the need for continuous education regarding pregnancy and oral health Lung T (2007) Parodontologie Clinică. Napoca Star, Cluj-Napoca, (Eds.), 15. Romania. conditions. Moreover, the update of the therapeutic approaches Yamoah KK, Lindow S, Karsai L (2009) A large epulis in pregnancy. J Ob- is essential in order to effectively prevent the risks such as pre- 16. stet Gynaecol 29(8): 761-762. eclampsia and premature birth [21]. The risks associated to the Khairallah A (2015) Dental care throughout pregnancy: Do`s and Don`ts. radiation exposure of a pregnant patient often results in inadequate 17. Smile Dental Journal 1(10): 16-20. dental care upon an emergency, and a study including 250 dentists Cengiz S (2007) The pregnant patient: Consideration for dental manage- in Tabriz, Iran, showed that the population did not have sufficient 18. ment and drug use. Quintessence International 3(38): 133-142. knowledge about the risk of performing dental radiographs during Shruthi P, Mohankumar K (2013) Awareness of Dental Treatment Proto- pregnancy. Most radiology specialist use during dental radiography col for Pregnant Women and Lactating Mother’s in General Dental Prac- titioners of Davangere District, Karnataka, India. Journal of Clinical and a sort lead 92% and only a few use a long rectangular collimator 19. Diagnostic Research 7(12): 3126. Conclusion3,2% [22]. Ajesh G, Simin S, Johnson M (2012) How Do Dental and Prenatal Care Practitioners Perceive Dental Care During Pregnancy? Current Evidence 20. and Implications. Birth 39(3): 238-247. As a general conclusion, the dentists included in our study had Zanata L, Barros Parnon K, Navarro Lopes P (2008) Prenatal dental care: insufficient knowledge regarding the particularities of the dental evaluation of professional knowledge of obstetricians and dentists in the treatments that can be performed in pregnant women. Therefore, cities of Londrina/PR and Bauru/SP, Brazil. Journal of Applied Oral Sci- ence 16(3): 194-200. Copyright@ 11195

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21. 22.

Boutigny H, de Moegen M, Egea L, Badran Z, Boschin F, et al. (2016) Oral Tahmineh R, Bazvand R, Ghojazadeh M (2011) Diagnostic Dental Radi- Infections and Pregnancy: Knowledge of Gynecologists/Obstetricians, ation Risk during Pregnancy: Awareness among General Dentists in Ta- Midwives and Dentists. Oral Health and Preventive Dentistry 14(1): 41- briz. Dental Research, Dental Clinics, Dental Prospects 5(2): 67-70. 47.

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